Patient Registration Form

Please correct the errors described below.

Mailing Address

Insurance Information

Must Present Insurance Card

I understand that if any of the insurance information I have provided in incorrect or if I fail to notify the once of any insurance changes, I am responsible for all physician charges. I hereby authorize the release of any medical information necessary for the processing of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Family Foot Care. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.

I have reviewed this information and is correct to the best of my knowledge.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient History


CHECK ANY THAT APPLY:

PREVIOUS SURGERIES OR SURGICAL PROCEDURES: (check)

FAMILY HISTORY

Condition:

CURRENT MEDICATIONS: (all prescriptions, vitamins, over-the-counter medications)

ALLERGIES

I certify that the above information is true and correct to the best of my knowledge. I give permission to the doctor to administer and perform such procedures as may be necessary in the diagnosis and/or treatment of my feet:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Authorization for Contact

Purpose of Request:

I authorize Family Foot Care to disclose my protected health information in the following manner:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Communication Transmittal Consent Form

Our doctors strive to maintain detailed and accurate medical records of your health care. This goal requires both verbal and written data to be entered into your medical record not only by physicians, but also by office staff, nurses and medical scribes. Verbal communication may be monitored during your visit to enable such detailed and accurate records to be created in a timely manner. All such communication is confidential and protected in order to maintain the privacy of your health information. By your signature below, you agree and consent to such monitoring for recordkeeping purposes. If you do not wish to have such communication monitored, you may opt out of the transmission by informing your physician of such decision.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Notice of Privacy Practices

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Portal Information

An invitation will be sent to the above email address. Click on the link and follow the instructions to access Family Foot Care’s Patient Portal. The last four digits of the patient’s social security number will need to be provided in order to access the Patient Portal. If you need assistance with the patient portal, please call 817-573-7178.

Your information will be encrypted.

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